Mindanao State University Iligan Institute of Technology

A. Bonifacio Ave., Iligan City

College of Arts and Social Sciences
Department of Psychology
(Gawad Kalinga Extension Program)
A.

PROFILING

Name: _________________________________________ Age: _____ Sex: _____

Highest Educational Attainment: ________________ Occupation_________________
Marital Status (please check):
Married

Single

Widow/widower

Legally Separated

Name of Spouse (if any): ____________________________ Age: _____ Sex: _____

Highest Educational Attainment: ________________ Occupation_________________
Permanent Address: ____________________________________________________
No. of Children: _____

How many are studying?: _____

How many are not studying?: _____

In Chronological order:
Name:

B.
I.

Age:

Name of School:

Needs Assessment
What are your present problems?

a. Family

Is your source of daily sustenance like food for the day enough?
______________________________________________________________

Are there any problems in household maintenance? If yes, cite some.

______________________________________________________________

How did you acquire your house?

______________________________________________________________

Indicate other problems not mentioned above.

_______________________________________________________________

b. Community

Are there any misunderstandings or quarrel between you and your neighbors?
If yes, cite the reason.
_______________________________________________________________

Are there any misunderstandings or quarrel between your kids and the
neighbors? if yes, cite the reason.
_______________________________________________________________

Is sanitation present in the environment? If no, cite the reason.

_______________________________________________________________

Is the water supply enough for the household consumption?

_______________________________________________________________

What can you say about the drainage system of the community?
_______________________________________________________________

Indicate other problems not mentioned above.

_______________________________________________________________

II.

Intervention/ Coping Mechanism (how self-concept is maintained)

How do you feel about your present condition?

________________________________________________________________

What motivates you to move on despite the problems?

________________________________________________________________

Aside from the needs of the family, what are your personal needs?
________________________________________________________________

Mindanao State University Iligan Institute of Technology

A. Bonifacio Ave., Iligan City
College of Arts and Social Sciences
Department of Psychology
(Gawad Kalinga Extension Program)
A.

PROFILING

Name: _________________________________________ Age: _____ Sex: _______

Grade Level: ___________ Name of School: _________________________________
Name of Father: ________________________________________________________
Highest Educational Attainment: ________________ Occupation_________________
Name of Mother: _______________________________________________________
Highest Educational Attainment: ________________ Occupation_________________
Permanent Address: ____________________________________________________
Ordinal position: ________

B.
I.

No. of brother/s: _______

No. of Sister/s: ________

Needs Assessment
What are your present problems?
a. Family

Are your parents fighting? If yes, cite the reason.

______________________________________________________________

Are you usually scolded by your parents? If yes, cite the reason.
______________________________________________________________

Do you usually quarrel with your siblings? If yes, cite the reason.
______________________________________________________________

Do you have enemies in your neighborhood? If yes, why did it happen?

______________________________________________________________

b. Community

Do you have enemies in your neighborhood? If yes, why did it happen?

______________________________________________________________

How do you feel about your studies and school?

______________________________________________________________

II.

Intervention/ Coping Mechanism (how self-concept is maintained)

How do you feel about your present condition?

________________________________________________________________

What motivates you to move on despite the problems?

________________________________________________________________

Aside from the needs of the family, what are your personal needs?
________________________________________________________________